Method and apparatus for soft tissue fixation

ABSTRACT

A tissue fixation apparatus can include a flexible construct and an elongated locking member. The flexible construct can include at least two adjustable loops and tensioning members. The two adjustable loops can be configured to pass through the first tissue, and to be spaced apart along an outer surface of the first tissue in a first direction. The tensioning members can extend from the two adjustable loops, and can be configured to reduce the two adjustable loops from a first size to a second size. The flexible construct can be attached to the second tissue by an anchor. The locking member can be configured to be received within the two adjustable loops at the first size, and to engage the two adjustable loops at the second size.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a continuation of United States patent Ser. No.14/182,038 filed on Feb. 17, 2014, now U.S. Pat. No. 9,763,656 issued onSep. 19, 2017, which is a divisional of U.S. patent application Ser. No.13/098,927 filed on May 2, 2011, now U.S. Pat. No. 8,652,171 issued onFeb. 18, 2014, which is a continuation-in-part of United. States patentapplication Ser. No. 12/196,398 filed on Aug. 22, 2008, now U.S. Pat.No. 7,959,650 issued on Jun. 14, 2011, which is a continuation-in-partof (a) U.S. patent application Ser. No. 11/541,506 filed on Sep. 29,2006, now U.S. Pat. No. 7,601,165 issued on Oct. 13, 2009; (b) U.S.patent application Ser. No. 11/935,681 filed on Nov. 6, 2007, now U.S.Pat. No. 7,905,903 issued on Mar. 15, 2011; and (c) U.S. patentapplication Ser. No. 11/784,821 filed on Apr. 10, 2007 now U.S. Pat. No.9,017,381 issued on Apr. 28, 2015.

This application is a continuation of United States patent Ser. No.14/182,038 filed on Feb. 17, 2014, now U.S. Pat. No. 9,763,656 issued onSep. 19, 2017, which is a divisional of U.S. patent application Ser. No.13/098,927 filed on May 2, 2011, now U.S. Pat. No. 8,652,171 issued onFeb. 18, 2014, which is a continuation-in-part of U.S. patentapplication Ser. No. 12/938,902 filed on Nov. 3, 2010, now U.S. Pat. No.8,597,327 issued on Dec. 3, 2013, which is a continuation-in-part ofU.S. patent application Ser. No. 12/915,962 filed on Oct. 29, 2010, nowU.S. Pat. No. 8,562,647 issued on Oct. 22, 2013, which is acontinuation-in-part of U.S. patent application Ser. No. 12/719,337filed on Mar. 8, 2010, now U.S. Pat. No. 9,078,644 issued on Jul. 14,2015, which is a continuation-in-part of United. States patentapplication Ser. No. 12/489,168 filed on Jun. 22, 2009, now U.S. Pat.No. 8,361,113 issued on Jan. 29, 2013, which is a continuation-in-partof U.S. patent application Ser. No. 12/474,802 filed on May 29, 2009,now U.S. Pat. No. 8,088,130 issued on Jan. 3, 2012, which is acontinuation-in-part of (a) U.S. patent application Ser. No. 12/196,405filed on Aug. 22, 2008, now U.S. Pat. No. 8,128,658 issued on Mar. 6,2012; (h) U.S. patent application Ser. No. 12/196,407 filed on Aug. 22,2008, now U.S. Pat. No. 8,137,382 issued on Mar. 20, 2012; (c) U.S.patent application Ser. No. 12/196,410 filed on Aug. 22, 2008, now U.S.Pat. No. 8,118,836 issued on Feb. 21, 2012; and (d) acontinuation-in-part of U.S. patent application Ser. No. 11/541,506filed on Sep. 29, 2006, now U.S. Pat. No. 7,601,165 issued on Oct. 13,2009.

This application is a continuation of U.S. patent Ser. No. 14/182,038filed on Feb. 17, 2014, now U.S. Pat. No. 9,763,656 issued on Sep. 19,2017, which is a divisional of U.S. patent application Ser. No.13/098,927 filed on May 2, 2011, now U.S. Pat. No. 8,652,171 issued onFeb. 18, 2014, which is a continuation-in-part of U.S. patentapplication Ser. No. 12/788,978 filed on May 27, 2010, now U.S. Pat. No.8,801,783 issued on Aug. 12, 2014.

This application is a continuation of United States patent Ser. No.14/182,038 filed on Feb. 17, 2014, now U.S. Pat. No. 9,763,656 issued onSep. 19, 2017, which is a divisional of U.S. patent application Ser. No.13/098,927 filed on May 2, 2011, now U.S. Pat. No. 8,652,171 issued onFeb. 18, 2014, which is a continuation-in-part of U.S. patentapplication Ser. No. 12/702,067 filed on Feb. 8, 2010, now U.S. Pat. No.8,672,968 issued on Mar. 18, 2014, which is a continuation of U.S.patent application Ser. No. 11/541,505 filed on Sep. 29, 2006, now U.S.Pat. No. 7,658,751 issued on Feb. 9, 2010.

This application is a continuation of U.S. patent Ser. No. 14/182,038filed on Feb. 17, 2014, now U.S. Pat. No. 9,763,656 issued on Sep. 19,2017, which is a divisional of U.S. patent application Ser. No.13/098,927 filed on May 2, 2011, now U.S. Pat. No. 8,652,171 issued onFeb. 18, 2014, which is a continuation-in-part of U.S. patentapplication Ser. No. 12/570,854 filed on Sep. 30, 2009, now U.S. Pat.No. 8,303,604 issued on Nov. 6, 2012, which is a continuation-in-partof: (a) U.S. patent application Ser. No. 12/489,181 filed on Jun. 22,2009, now U.S. Pat. No. 8,298,262 issued on Oct. 30, 2012; (b) U.S.patent application Ser. No. 12/014,399 filed on Jan. 15, 2008, now U.S.Pat. No. 7,909,851 issued on Mar. 22, 2011, which is acontinuation-in-part of U.S. patent application Ser. No. 11/347,661filed on Feb. 3, 2006, now U.S. Pat. No. 7,749,250 issued on Jul. 6,2010; and (c) U.S. patent application Ser. No. 12/014,340 filed on Jan.15, 2008, now U.S. Pat. No. 7,905,904 issued on Mar. 15, 2011.

The entire disclosures of the aforementioned references are expresslyincorporated herein by reference.

FIELD

The present disclosure relates to methods and apparatuses for securingsoft tissue using a flexible suture construct and, more particularly, toflexible suture constructs including adjustable loops.

BACKGROUND

This section provides background information related to the presentdisclosure which is not necessarily prior art.

Surgical procedures are often performed on a body, for example, a humanbody or anatomy, to repair or replace various portions thereof. Forexample, the soft tissues of the body may need to be reattached to bonesor a tear in the soft tissue may need repaired due to trauma, overuse,surgical intervention, or disease.

Soft tissues can be reattached to a bone or repaired using fasteningdevices such as screws, staples, and various types of suture anchors.Soft tissues are often fixed to various positions on the bone. Forexample, to replace a natural tendon fixation point or to replace thetendon itself, it may be desired to fix a graft to a selected bone area.One method of fixing a soft tissue to the selected area is to pass oneend of a suture through a selected portion of the soft tissue to form aknot and fix another end of the suture to a selected area on the bonewith a suture anchor. The present teachings provide surgical methods andapparatuses for improving engagement between a suture construct and asoft tissue.

SUMMARY

This section provides a general summary of the disclosure, and is not acomprehensive disclosure of its full scope or all of its features.

The present teachings provide surgical methods of attaching a firsttissue to a second tissue. In one example, an exemplary method caninclude passing at least two adjustable loops through at least the firsttissue to extend from an outer surface of the first tissue opposite atissue engaging surface facing the second tissue, and attaching the twoadjustable loops to a first selected area of the second tissue. Themethod can further include positioning a locking member within the twoadjustable loops such that the locking member extends between the twoadjustable loops adjacent the outer surface, engaging the locking memberwith the outer surface by drawing the two adjustable loops towards theouter surface, and compressing the first tissue between the lockingmember and the second tissue by tensioning the two adjustable loops.

In another example, the method can include attaching a suture anchorincluding a flexible construct to the second tissue, wherein theflexible construct extends from the suture anchor and includes at leasttwo self-locking adjustable loops and tensioning members extending fromthe two adjustable loops. The method can further include passing the atleast two self-locking adjustable loops and the tensioning membersthrough the first tissue to extend from an outer surface of the firsttissue opposite a tissue engaging surface facing the second tissue. Themethod can further include positioning an elongated locking memberwithin the two self-locking adjustable loops such that the lockingmember extends between the two self-locking adjustable loops adjacentthe outer surface. The method can further include cinching the twoself-locking adjustable loops around the locking member by selectivelypulling on the tensioning members, engaging the locking member with theouter surface of the first tissue, and compressing the first tissuebetween the locking member and the second tissue by selectively pullingon the tensioning members.

In another example, the method can include attaching a self-locking,first adjustable loop to a first anchor at a first end of the firstadjustable loop and a second anchor at a second end of the firstadjustable loop, wherein the first adjustable loop includes a firsttensioning member. The method can further include attaching aself-locking, second adjustable loop to a third anchor at a first end ofthe second adjustable loop and a fourth anchor at a second end of thesecond adjustable loop, wherein the second adjustable loop includes asecond tensioning member. The method can further include passing thefirst ends of the first and second adjustable loops through separateapertures in the first tissue to extend from an outer surface of thefirst tissue opposite a tissue engaging surface facing the secondtissue. The method can further include attaching the first and thirdanchors to the second tissue in a first selected area overlapping thefirst tissue, and attaching the second and fourth anchors to the secondtissue in a second selected area spaced apart from the first selectedarea. The method can further include positioning a locking memberbetween the outer surface and the first and second adjustable loops, andengaging the first and second adjustable loops with the locking memberby pulling on the first and second tensioning members. The method canfurther include engaging the locking member with the outer surface ofthe first tissue, and compressing the first tissue between the lockingmember and the second tissue by pulling on the first and secondtensioning members. The second selected area can be disposed adjacent anend of the first tissue.

The present teachings also provide tissue fixation apparatuses that canbe used to attach a first tissue to a second tissue. In one example, anexemplary tissue fixation apparatus can include a flexible construct andan elongated locking member. The flexible construct can include at leasttwo adjustable loops, tensioning members, and an anchor. The twoadjustable loops can be configured to pass through the first tissue, andto be spaced apart along an outer surface of the first tissue in a firstdirection. The tensioning members can extend from the two adjustableloops, and can be configured to reduce the two adjustable loops from afirst size to a second size. The anchor can be configured to attach theflexible construct to the second tissue in a first selected area of thesecond tissue. The locking member can be configured to be receivedwithin the two adjustable loops at the first size, and to engage the twoadjustable loops at the second size.

Further areas of applicability will become apparent from the descriptionprovided herein. The description and specific examples in this summaryare intended for purposes of illustration only and are not intended tolimit the scope of the present disclosure.

DRAWINGS

The drawings described herein are for illustrative purposes only ofselected embodiments and not all possible implementations, and are notintended to limit the scope of the present disclosure.

FIGS. 1-3 are fragmentary side views illustrating an exemplary tissuefixation device and method for affixing two tissues together using thetissue fixation device according to the present teachings;

FIGS. 4-6 are fragmentary environmental perspective views illustratingan exemplary method of using the tissue fixation device shown in FIGS.1-3 to affix a rotator cuff to a humerus;

FIG. 7 is a perspective view illustrating an exemplary locking memberaccording to the present teachings;

FIG. 8 is a fragmentary top view illustrating another exemplary lockingmember according to the present teachings;

FIG. 9 is a fragmentary top view illustrating another exemplary lockingmember according to the present teachings;

FIG. 10 is a top view illustrating an exemplary adjustable lockingmember according to the present teachings;

FIG. 11 is a top view illustrating another exemplary adjustable lockingmember according to the present teachings;

FIG. 12 is a top view illustrating another exemplary adjustable lockingmember according to the present teachings;

FIG. 13 is a top view illustrating another exemplary adjustable lockingmember according to the present teachings;

FIG. 14 is a top view illustrating another exemplary adjustable lockingmember according to the present teachings;

FIG. 15 is a fragmentary side view illustrating an exemplary method forcoupling a locking member to a flexible suture construct according tothe present teachings;

FIG. 16 is a fragmentary side view illustrating another exemplary methodfor coupling a locking member to a flexible suture construct accordingto the present teachings;

FIG. 17 is a fragmentary environmental perspective view illustratinganother exemplary method for affixing a rotator cuff to a humerus usinganother tissue fixation device according to the present teachings;

FIG. 18 is a fragmentary environmental perspective view illustratinganother exemplary method for affixing a rotator cuff to a humerus usinganother tissue fixation device according to the present teachings;

FIG. 19 is a fragmentary environmental perspective view illustratinganother exemplary method for affixing a rotator cuff to a humerus usinganother tissue fixation device according to the present teachings;

FIG. 20 is a fragmentary environmental perspective view illustratinganother exemplary method for affixing a rotator cuff to a humerus usinganother tissue fixation device according to the present teachings;

FIG. 21 is an environmental perspective view illustrating anotherexemplary method for affixing two tissues together using another tissuefixation device according to the present teachings;

FIG. 22 is a view illustrating a flexible loop construct according tothe present teachings; and

FIGS. 23-24 are fragmentary environmental perspective views illustratinganother exemplary tissue fixation device and method of using the tissuefixation device for affixing a rotator cuff to a humerus.

Corresponding reference numerals indicate corresponding parts throughoutthe several views of the drawings.

DETAILED DESCRIPTION

Example embodiments will now be described more fully with reference tothe accompanying drawings.

With particular reference to FIGS. 1-3, an exemplary tissue fixationdevice (TFD) 10 for affixing a first tissue 12 to a second tissue 14 isshown. The first tissue 12 and the second tissue 14 can be independentlyselected from soft tissue or bone to provide any one of a softtissue-to-bone, a soft tissue-to-soft tissue, or a bone-to-boneconnection. For purposes of the example shown in FIGS. 1-3, a softtissue-to-bone connection is described. Various components of the TFD 10are described first and then various surgical methods for affixing thefirst tissue 12 to the second tissue 14 using the TFD 10 are described.

Generally, the TFD 10 can be composed of various biocompatiblematerials, including bioresorbable and non-bioresorbable materials. TheTFD 10 can include a flexible suture construct 20, a suture anchoringmember 22, and a locking member 24. Generally, the suture construct 20can be formed of a monofilament, a braided fiber or strand, or otherflexible member or suture used to affix the tissues 12, 14. The sutureconstruct 20 can include at least two adjustable loops 30, 32 and atleast one tensioning member 34. In various implementations, asillustrated by the examples discussed below, a tensioning member 34 maybe provided for each of the loops 30, 32. Additionally, the loops 30, 32and the tensioning member or members 34 can be formed from a singlesuture construct.

Together, the loops 30, 32 and the tensioning member or members 34 cancooperate to cinch the loops 30, 32 and to create tension in the sutureconstruct 20. In this way, the loops 30, 32 and the tensioning member ormembers 34 can cooperate to draw and/or compress the tissues 12, 14together. The loops 30, 32 can be adapted to both receive and engage thelocking member 24. In various implementations, the loops 30, 32 can beself-locking adjustable loops, as illustrated by the examples discussedbelow. Together, the loops 30, 32 and the locking member 24 cancooperate to engage a major or outer surface 36 of the first tissue 12opposite a tissue engaging surface 38 to be engaged with the secondtissue 14. The tensioning member or members 34 can be configured toadjust the suture construct 20 between an untensioned state and atensioned state.

The loops 30, 32, the tensioning member or members 34, and/or the sutureanchoring member 22 can be created using various surgical methods andsuture constructs. For example, whip and/or mattress stitching methodsemploying a suture thread can be used. As another example, self-lockingadjustable loop suture constructs can be employed. Exemplaryself-locking adjustable loop suture constructs are disclosed in commonlyassigned U.S. Pat. Nos. 7,658,751 and 7,601,165, the entire disclosuresof which are expressly incorporated herein by reference.

According to the example shown in FIGS. 1-3, the suture construct 20 caninclude a braided body 40 and tensioning strands 42, 44 that formself-locking adjustable loops 30, 32 and separate tensioning members 34for each of the loops 30, 32. The braided body 40 and the tensioningstrands 42, 44 can be formed in a single suture construct using abraiding process for braiding fibers composed of a biocompatiblematerial. The braided body 40 can define a longitudinal passage 50 andapertures 52, 54 longitudinally spaced along and in communication withthe longitudinal passage 50. The apertures 52, 54 can be created duringthe braiding process as loose portions between pairs of fibers. Thetensioning strands 42, 44 can be created using one or more of the fibersused to create the braided body. In this way, the tensioning strands 42,44 can be integral to the braided body 40.

An end 56 of the tensioning strand 42 can be inserted through theaperture 52 and passed through the longitudinal passage 50 and out theaperture 54 to create the loop 30. Similarly, an end 58 of thetensioning strand 44 can be inserted through the aperture 54 and passedthrough the longitudinal passage 50 and out the aperture 52 to createthe loop 32. Sizes or diameters of the loops 30, 32 can be adjusted byretracting or advancing the tensioning strands 42, 44, respectively,within the longitudinal passage 50.

The suture anchoring member 22 can be configured to affix the sutureconstruct 20 to the second tissue 14. In various implementations, thesuture anchoring member 22 can be created by the suture construct 20alone, or in combination with, a separate component. According to theexample shown in FIGS. 1-3, the suture anchoring member 22 can be aseparate fastener or suture anchor 60 including external threads 62configured to threadingly engage the second tissue 14 and an eyelet 64configured to receive the braided body 40. It should be understood thatthe suture anchor 60 is merely exemplary in nature, and that othersuture anchors can be used. For example, threaded or non-threaded sutureanchors can be used. The suture anchor 60 can be composed of variousbioresorbable materials such as, for example, the LactoSorb® materialavailable from Biomet Sports Medicine, LLC of Warsaw, Ind. Alternately,or additionally, the suture anchor may be composed of othernon-bioresorbable materials, such as, for example, titanium-basedmaterials. Various bioresorbable and non-bioresorbable, soft and hardsuture anchors are available from, for example, Biomet Sports Medicine,LLC of Warsaw, Ind.

The locking member 24 can be an elongated member that is received withineach of the loops 30, 32, and that spans a lateral distance between theloops 30, 32. The locking member 24 can be further configured to engageand thereby restrain the loops 30, 32 from pulling through the firsttissue 12 and to maintain the lateral distance between the loops 30, 32,when the suture construct 20 is in the tensioned state. For example, thelocking member 24 can be constructed to have a predetermined strengthfor a period after implantation for resisting pull through by the loops30, 32. The locking member 24 can be further sized to provide apredetermined bearing surface for distributing compressive loads to thefirst tissue 12 generated by the suture construct 20 in the tensionedstate. More specifically, the locking member 24 can transmit compressiveloads received from the loops 30, 32 to the first tissue 12.

Generally, the locking member 24 can be composed of variousbioresorbable or non-bioresorbable materials. The locking member 24 caninclude flexible and/or semi-rigid sections that enable the lockingmember 24 to conform to the outer surface 36 of the first tissue 12, yetdistribute the compressive loads to the first tissue 12 in apredetermined manner. According to the example shown in FIGS. 1-3, thelocking member 24 can be a length of a flexible strip of surgical fabricsuch as, for example, surgical tape. The surgical tape can includebraided fibers. The locking member 24 can be cut to a predeterminedlength and/or cut to a custom length during a surgical procedure basedon a particular patient.

With additional reference to FIGS. 4-6, an exemplary surgical method foraffixing the tissues 12, 14 together using the TFD 10 according to thepresent teachings will now be described. For exemplary purposes, themethod includes affixing a rotator cuff 70 to a humerus 72. In variousimplementations, the TFD 10 and the corresponding method can include twoor more suture constructs, such as the suture construct 20, with asingle locking member, such as the locking member 24. As illustrated inFIGS. 4-6, the TFD 10 can further include a second suture construct 20′substantially similar to the suture construct 20. The second sutureconstruct 20′ can be coupled to the second tissue 14 via a second sutureanchoring member 22′ substantially similar to the suture anchoringmember 22. For purposes of the following description, correspondingreference numerals are used to indicate corresponding parts of thesuture constructs 20, 20′ throughout the several views of the drawings.

With continued reference to FIGS. 1-6, the method can include preparingthe humerus 72 to receive suture anchoring members 22, 22′ in a selectedarea where the rotator cuff 70 is to be attached. The humerus 72 can beprepared by creating threaded holes in the humerus 72 in selected areas,each at a desired angle of insertion. The threaded holes can be createdto a depth that enables the suture anchoring members 22, 22′ and/orportions of the suture constructs 20, 20′ to be located beneath an outersurface of the humerus 72.

Next, suture constructs 20, 20′ can be coupled to the humerus 72 via thesuture anchoring members 22, 22′, respectively. The suture constructs20, 20′ can be coupled to the suture anchoring members 22, 22′ prior to,at the same time, or after securing the suture anchoring members 22, 22′to the humerus 72. According to the examples shown in FIGS. 1-6, thesuture construct 20 can be coupled to the suture anchoring member 22prior to threadingly engaging the suture anchoring member 22 with thehumerus 72. More particularly, tensioning strand 42 can be insertedthrough the eyelet 64 until the braided body 40 is approximatelycentered within the eyelet 64. Next, the tensioning strands 42, 44 canbe passed through the longitudinal passage 50 to create the loops 30, 32as discussed above. The suture construct 20′ can be coupled to thesuture anchoring member 22′ and subsequently to the tissue 14 in asimilar manner.

Next, with particular reference to FIG. 4, the loops 30, 32 andtensioning strands 42, 44 can be passed through incisions or apertures80, 82 formed into the rotator cuff 70. Similarly, the loops 30′, 32′and tensioning strands 42′, 44′ can be passed through apertures 84, 86of the rotator cuff 70. The apertures 80, 82, 84, 86 can be spaced apartand can extend generally parallel to one another as shown. In variousimplementations, one or more of the tensioning strands 42, 44, 42′, 44′can be passed between the tissues 12, 14, rather than through thecorresponding apertures 80, 82, 84, 86. The apertures 80, 82, 84, 86 canbe created prior to or at the same time as the passing of thecorresponding loops 30, 32, 30′, 32′ and the tensioning strands 42, 44,42′, 44′. The loops 30, 32, 30′, 32′ and tensioning strands 42, 44, 42′,44′ can be passed using a separate needle or other suitable suturepasser or device. For example, suitable devices include devices soldunder the trade names “BiPass™”, SpeedPass™”, and “ArthroPass™”, allmade by Biomet Sports Medicine, LLC of Warsaw, Ind.

The loops 30, 32, 30′, 32′ can be passed such that distal ends of theloops 30, 32, 30′, 32′ are spaced apart along a major or outer surface88 of the rotator cuff 70. The loops 30, 32, 30′, 32′ can be spacedapart along a line or axis 89 to face or open towards each other asshown. The loops 30, 32, 30′, 32′ can be spaced apart to span a selectedarea of the rotator cuff 70 to be attached to the humerus 72. Thetensioning strands 42, 44, 42′, 44′ can be passed through the sameapertures 80, 82, 84, 86 as the corresponding loops 30, 32, 30′, 32′ asshown, or through separate, spaced apertures as discussed in furtherdetail below. Next, as shown between FIGS. 4-5, the locking member 24can be passed through and positioned within each of the loops 30, 32,30′, 32′. Sizes or diameters of the loops 30, 32, 30′, 32′ can beadjusted to enable the locking member 24 to be passed through the loops30, 32, 30′, 32′. The diameters can be adjusted as discussed above priorto or when positioning the locking member 24.

With the locking member 24 thus positioned, the tensioning strands 42,44, 42′, 44′ can be selectively pulled to cinch the loops 30, 32, 30′,32′ around the locking member 24 and to draw the locking member 24 intoengagement with the rotator cuff 70. With the locking member 24 engaged,the tensioning strands 42, 44, 42′, 44′ can be further pulled to furtherclose and tension the loops 30, 32, 30′, 32′ and draw the locking member24 towards the suture anchoring members 22, 22′. Further drawing thelocking member 24 can draw the rotator cuff 70 in close proximity withthe humerus 72 and subsequently compress the rotator cuff 70, therebycreating tension in the suture constructs 20, 20′. More specifically,the rotator cuff 70 can be drawn into a desired relationship with thehumerus 72. FIGS. 1 and 4 illustrate the suture constructs 20, 20′ in anuntensioned state. FIGS. 2, 3, and 5 illustrate the suture constructs20, 20′ in a tensioned state.

Tension in the loops 30, 32, 30′, 32′ can be retained by theself-locking features of the constructs 20, 20′ without continuing topull on the tensioning strands 42, 44, 42′, 44′. Although notspecifically shown, with the rotator cuff 70 and the humerus 72 in thedesired relationship, one or more of the tensioning strands 42, 44, 42′,44′ can be cut to a desired length, for example, flush to the outersurface 88. In this way, excess length can be removed. Alternately, thetensioning strands 42, 44, 42′, 44′ can be drawn past an end of therotator cuff 70 and attached to a selected area of the humerus 72 asshown in FIG. 6. More particularly, the tensioning strands 42, 44, 42′,44′ can be drawn and attached so as to extend in a direction generallyparallel to a direction in which the rotator cuff 70 contracts duringmuscle action. Tensioning strands 44, 44′ can be drawn around thelocking member 24 and positioned to adjoin the loops 32, 32′,respectively, as shown.

The tensioning strands 42, 44, 42′, 44′ can be attached using anothersuture anchoring member 90 substantially similar to the suture anchoringmember 22. The tensioning strands 42, 44, 42′, 44′ can be coupled to thesuture anchoring member 90 by passing the tensioning strands 42, 44,42′, 44′ through an eyelet 92 of the suture anchoring member 90 andcreating a knot 94. The humerus 72 can be prepared to receive the sutureanchoring member 90 in substantially the same manner as the sutureanchoring members 22, 22′.

With particular reference to FIGS. 7-14, various other exemplaryconfigurations of the locking member 24 according to the presentteachings are shown. FIGS. 7-9 illustrate various flexible, elongated,and generally thin, flat configurations that can be cut to a desiredlength and/or width from a larger stock of material prior to and/orduring a surgical procedure. With particular reference to FIG. 7, anexemplary locking member 100 can include monofilament fibers 102, 104connected along a length by a fabric of intertwined threads, or braidedfabric 106. The monofilament fibers 102, 104 can have diameters greaterthan a thickness of the braided fabric 106. The braided fabric 106 cancircumscribe the monofilament fibers 102, 104 and include a centralsection 108 that spans a width between the monofilament fibers 102, 104.The locking member 100 can be oriented between adjacent loops (e.g.,loops 30, 32) of a suture construct so that the monofilament fibers 102,104 span a distance between the loops. Alternately, the locking member100 can be oriented so that the central section 108 spans the distancebetween the loops and the larger side sections created by themonofilament fibers 102, 104 engage opposite sides of the loops. In thisway, the monofilament fibers 102, 104 can provide a loop engagingfeature for fixing ends of the locking member 100 relative to the loopsand/or for fixing the distance between the loops.

Referring now to FIG. 8, another exemplary locking member 120 caninclude outwardly extending edges or protrusions 122, 124 that createperipheral recesses along a length that are configured to engage two ormore loops (e.g., loops 30, 32) of a suture construct. At least twoprotrusions 122, 124 can be provided to fixedly position the loops andthereby maintain a distance between the loops when the loops areengaged. The protrusions 122, 124 can extend at an angle, for exampletowards each other, to create barbs or hooks as shown for engaging andsecurely holding the loops at a separated distance. In an exemplaryconstruction, the locking member 120 can include monofilament fibers 126connected along a length by a braided fabric 128 in a substantiallysimilar way as the locking member 100. The protrusions 122, 124 can becreated using various methods. For example, the protrusions 122, 124 canbe created during the braiding process used to create the braided fabric128. As another example, a cutting process, for example a die cuttingprocess, can be used to create the protrusions 122, 124.

Referring now to FIG. 9, another exemplary locking member 140 caninclude a length or strip of a non-woven bio-textile 142, such as, forexample, the Scaftex® materials offered by Biomedical Structures ofWarwick, R.I. Non-woven bio-textiles can be manufactured from a varietyof synthetic, absorbable polymeric fibers, including polyglycolic acid(PGA), poly-L-lactide (PLLA), poly DL-lactide-co-glycolide acid (PLGA),blends, and other fibers. The bio-textile 142 can include first regions144 having a higher density than second regions 146. The first andsecond regions 144, 146 can have a predetermined and regular arrangementwith respect to a broad or major surface of the locking member 140configured to engage loops of a suture construct. The bio-textile 142can be die cut from a sheet to include peripheral depressions 148 alongopposite sides configured to engage the loops of the suture construct.The peripheral depressions 148 can adjoin the higher density firstregions 144. In this way, the loops can engage and be retained in higherdensity regions specifically suited to restrain the loops from pullingthrough the adjoining tissue.

FIGS. 10-14 illustrate various adjustable locking members according tothe present teachings. Generally, the locking members are flexible andelongate configurations created using various adjustable loopconstructions. The adjustable loop constructions can enable adjustmentsto sizes or diameters of one or more loop sections and an overall lengthof the locking members prior to and during a surgical procedure. Theadjustments can further enable loop engaging members at opposite ends ofthe locking members to be brought into engagement with one or more loopsof a suture construct. The loop engaging members can be deformablebetween a first configuration when the locking members are untensionedand/or unengaged with loops of a suture construct and a secondconfiguration facilitating engagement between the locking members andthe loops. Additional suitable adjustable loop constructions aredisclosed in commonly assigned U.S. patent application Ser. No.11/541,506, the entire disclosure of which is expressly incorporatedherein by reference.

With particular reference to FIG. 10, an exemplary adjustable lockingmember 160 can include an adjustable loop construct including a sleeve162, a fiber or strand 164, and sleeves 166, 168. The sleeve 162 canhave a braided construction and can define a longitudinal passage 170and apertures 172, 174. The strand 164 can be wrapped into a single loopor coil passing through the longitudinal passage 170 and the sleeves166, 168 as shown to create adjustable loop sections that extend fromopposite ends of the sleeve 162. Ends 176, 178 of the strand 164 canpass through the apertures 172, 174 and can be used as tensioningmembers used to adjust sizes or diameters of the adjustable loopsections and thereby adjust an overall length of the locking member 160or, more specifically, a distance between the sleeves 166, 168. Thesleeves 166, 168 can have a braided construction similar to the sleeve162 and can function as loop engaging members.

Referring now to FIG. 11, another exemplary adjustable locking member180 can include an adjustable loop construct including a fiber or strand182 and sleeves 184, 186. The strand 182 can be wrapped into a singleloop or coil passing through the sleeves 184, 186 as shown to create anadjustable closed loop configuration. Ends 188, 190 of the strand 182can extend through the sleeves 184, 186 and exit at opposite ends of thesleeve 184. A size or diameter of the loop or coil and an overalldistance between the sleeves 184, 186 can be adjusted by pulling on oneor both the first and second ends 188, 190. The sleeves 184, 186 caninclude flexible sections to facilitate adjustments and/or semi-rigidsections to maintain a predetermined curvature or diameter of thesleeves 184, 186 after the adjustments. The sleeves 184, 186 can alsofunction as loop engaging members deformable between a firstconfiguration and a second configuration. The first configuration can bea first shape configured to maintain an overall shape of the lockingmember 180 prior to engaging the locking member 180 with loops of asuture construct, for example, the shape shown in FIG. 11. The secondconfiguration can be a second shape different from the first shapeconfigured to facilitate engagement between the locking member 180 andthe loops of the suture construct, for example, the cinched shape shownin FIG. 16 and discussed below.

Referring now to FIG. 12, another exemplary adjustable locking member200 can include a self-locking adjustable loop construct formed from abraided suture construct. The locking member 200 can include a braidedbody 202, fibers or strands 204, 206, and sleeves 208, 210. The braidedbody 204 can have a longitudinal passage 212 and apertures 214, 216. Thelongitudinal passage 212 and the apertures 214, 216 can be sizedrelative to the strands 204, 206 to provide the self locking feature. Afirst end 217 of the strand 204 can be passed through the sleeve 208,then through the aperture 214 and the longitudinal passage 212 and outthe aperture 216 to create a first self-locking adjustable loop at oneend of the adjustable locking member 200. A second end 219 of the strand206 can be passed through the sleeve 210, then through the aperture 216and the longitudinal passage 212 and out the aperture 214 to create asecond self-locking adjustable loop at an opposite end.

The apertures 214, 216 can be loose portions between pairs of fibersforming the braided body 204. While two apertures 214, 216 are shown,additional apertures can be provided so that each of the strands 204,206 can be passed through separate apertures to create the adjustableloops. Sizes or diameters of the adjustable loops can be separatelyadjusted by selectively pulling on the first and second ends 217, 219.By adjusting the diameter of one or both of the loops, an overall lengthof the adjustable locking member 200 and, more particularly, a distancebetween the sleeves 208, 210 can be adjusted.

Referring now to FIG. 13, another exemplary adjustable locking member220 can include an adjustable loop construct including a tubular body222, a fiber or strand 224, and sleeves 226, 228. The strand 224 can bewound in a single loop or coil passing through the tubular body 222 andthe sleeves 226, 228, as shown, to create two adjustable loop sectionsextending from opposite ends of the tubular body 222. First and secondends 230, 232 of the strand 224 can pass through the tubular body 222 toexit at one of the opposite ends. The first end 230 can be a free endthat functions as a tensioning member that can be pulled tosimultaneously adjust sizes or diameters of the adjustable loop sectionsand thereby adjust a distance between the sleeves 226, 228. The secondend 232 can be tied in a knot 234 that engages the tubular body 222 toprevent the second end 232 from pulling through the tubular body 222when making adjustments.

Referring now to FIG. 14, another exemplary adjustable locking member240 can include an adjustable loop construct including a fiber or strand242 and sleeves 244, 246. The strand 242 can be wound into a single loopor coil passing through the sleeves 244, 246, as shown, to create anadjustable closed loop configuration similar to that of the lockingmember 180 discussed above. First and second ends 248, 250 can exitopposite ends of the sleeve 244. The first end 248 can be a free endthat functions as a tensioning member. The second end 250 can be tied ina knot 252 that engages the sleeve 244 to prevent the second end 250from pulling through the sleeve 244 when pulling on the first end 248 tomake adjustments.

With particular reference to FIG. 15, another TFD 300 and surgicalmethod for using the TFD 300 for affixing the first tissue 12 to thesecond tissue 14 is shown. The TFD 300 and the method illustratealternate features that can be employed to engage a locking member withtwo or more loops of a suture construct, according to the presentteachings. For exemplary purposes, the TFD 300 can include the sutureconstructs 20, 20′ and the suture anchoring members 22, 22′. The TFD 300can further include a locking member 310. The locking member 310 canincorporate one or more features of the locking members 24, 100, 120,140, 160, 180, 200, 220, 240 discussed above. According to the exampleshown in FIG. 15, the locking member 310 can be a fiber or strand 320having first and second ends 322, 324.

With continued reference to FIG. 15, an exemplary method of using theTFD 300 can include coupling the suture constructs 20, 20′ to the secondtissue 14 and passing the loops 30, 32, 30′, 32′ through the firsttissue 12 in substantially the same manner as described above for theTFD 10. Next, with the suture constructs 20, 20′ in an untensionedstate, the first end 322 can be passed through a first end loop, forexample, the loop 30′, and then successively through the remaining loops32′, 32, 30 in that order. Next, the strand 320 can be wrapped around asecond end loop, here, the loop 30, by pulling the first end 322 backtowards the adjacent loop 32. Next, the first end 322 can besuccessively passed back through the loops 32, 32′, 30′ in that order.

Once the strand 320 is routed through the loops 30, 32, 30′, 32′ in theforegoing manner, the tensioning strands 42, 44, 42′, 44′ can beselectively pulled to cinch the loops 30, 32, 30′, 32′ around the strand320 and to draw the strand 320 into engagement with the first tissue 12.With the strand 320 engaged, a distance between the loops 30, 30′ can beadjusted by manipulating (e.g., pulling) one or both the first andsecond ends 322, 324. Next, the first and second ends 322, 324 can besecured together using a knot 326 that functions as a loop engagingmember that engages the loop 30′ and thereby inhibits the loops 30, 30′from separating during subsequent steps.

Next, the tensioning strands 42, 44, 42′, 44′ can be further selectivelypulled to draw the loops 30, 32, 30′, 32′ and the strand 320 towards thesuture anchoring members 22, 22′. Further drawing the loops 30, 32, 30′,32′ can draw the first tissue 12 in close proximity with the secondtissue 14 in a desired relationship, and subsequently compress the firsttissue 12, thereby creating tension in the suture constructs 20, 20′.FIG. 15 illustrates the suture constructs 20, 20′ in a tensioned state.With the first and second tissues in the desired relationship, thetensioning strands 42, 44, 42′, 44′ can be drawn under tension andattached to a selected area of the second tissue 14 in any suitablemanner. For example, the tensioning strands 42, 44, 42′, 44′ can beattached in a manner substantially similar to that described above forthe TFD 10.

With particular reference to FIG. 16, another TFD 400 and surgicalmethod for using the TFD 400 for affixing the first tissue 12 to thesecond tissue 14 will now be described. The TFD 400 and the methodillustrate alternate features according to the present teachings thatcan be employed to engage loop engaging members of an adjustable lockingmember with two or more loops of a suture construct. For purposes of theexample shown in FIG. 16, the locking member 180 shown in FIG. 11 can beemployed in the TFD 400. The TFD 400 can include the suture constructs20, 20′ and the suture anchoring members 22, 22′.

With reference to FIG. 11 and FIG. 16, an exemplary method of using theTFD 400 can include coupling the suture constructs 20, 20′ to the secondtissue 14 and passing the loops 30, 32, 30′, 32′ through the firsttissue 12 in substantially the same manner as described above for theTFD 10. Next, with the TFD 400 in an untensioned state, the lockingmember 180 can be passed through and positioned within the loops 30, 32,30′, 32′ such that ends of the locking member 180 extend past the endloops 30, 30′. More particularly, the locking member 180 can bepositioned such that the sleeves 184, 186 are disposed outboard of theend loops 30, 30′.

Once the locking member 180 is routed through the loops 30, 32, 30′, 32′in the foregoing manner, the tensioning strands 42, 44, 42′, 44′ can beselectively pulled to cinch the loops 30, 32, 30′, 32′ around thelocking member 180 and to draw the locking member 180 into engagementwith the first tissue 12. With the locking member 180 engaged, thesleeves 184, 186 can be brought into engagement with the loops 30, 30′,respectively, by pulling on one or both the ends 188, 190. The sleeves184, 186 can deform from a first configuration having a first shape (seeFIG. 11) to a second configuration having a cinched shape as shown inFIG. 16 that resists pull through. Once the sleeves 184, 186 areengaged, a distance between the loops 30, 30′ can be reduced by furtherpulling on one or both of the ends 188, 190. Next, the first and secondends 188, 190 can be tied together to create the knot 326 that engagesthe sleeve 184 and thereby fixes the length of the locking member 180and the distance between the loops 30, 30′.

Next, the tensioning strands 42, 44, 42′, 44′ can be further selectivelypulled to draw the locking member 180 towards the suture anchoringmembers 22, 22′. Further drawing the loops 30, 32, 30′, 32′ can draw thefirst tissue 12 in close proximity with the second tissue 14 in adesired relationship and subsequently compress the first tissue 12,thereby creating tension in the suture constructs 20, 20′. FIG. 16illustrates the suture constructs 20, 20′ in a tensioned state. With thefirst and second tissues 12, 14 in the desired relationship, thetensioning strands 42, 44, 42′, 44′ can be drawn under tension andattached to a selected area of the second tissue 14 in any suitablemanner. For example, the tensioning strands 42, 44, 42′, 44′ can beattached in a manner substantially similar to that described above forthe TFD 10.

With particular reference to FIG. 17, another TFD 500 and surgicalmethod of using the TFD 500 for affixing two tissues according to thepresent teachings will now be described. The TFD 500 can be used, forexample, to affix the rotator cuff 70 to the humerus 72. The TFD 500 andthe method illustrate alternate features according to the presentteachings including coupling ends of a locking member with a tensioningmember of a suture construct. In this way, the locking member can assistthe suture construct to resist tension generated in one or both thetissues due to muscle contraction.

For purposes of the example shown in FIG. 17, the TFD 500 can includethe self-locking suture constructs 20, 20′, the suture anchoring members22, 22′, and a locking member 502. The locking member 502 can be similarto the locking member 24, except that the locking member 502 can have alength sufficient to enable ends 504, 506 to be coupled to the humerus72 at one or more remote locations. For example, the ends 504, 506 canbe coupled at the locations separate from the locations where thelocking member 502 is coupled via the suture anchoring members 22, 22′.According to the example shown in FIG. 17, the ends 504, 506 can becoupled to the humerus 72 along with the tensioning strands 42, 44, 42′,44′ via a suture anchoring member 508. The ends 504, 506 can be coupledto the suture anchoring member 508 via a knot or other suitable lockingdevice.

With continued reference to FIG. 17, an exemplary method of using theTFD 500 can include coupling the suture constructs 20, 20′ to thehumerus 72 and passing the loops 30, 32, 30′, 32′ through the rotatorcuff 70 in substantially the same manner as described above for the TFD10. Next, with the TFD 500 in an untensioned state, the locking member502 can be passed through and positioned within the loops 30, 32, 30′,32′ such that the ends 504, 506 extend past the end loops 30, 30′.

Once the locking member 502 is routed through the loops 30, 32, 30′, 32′in the foregoing manner, the tensioning strands 42, 44, 42′, 44′ can beselectively pulled to cinch the loops 30, 32, 30′, 32′ around thelocking member 502 and to draw the locking member 502 into engagementwith the rotator cuff 70. Next, the tensioning strands 42, 44, 42′, 44′can be further selectively pulled to draw the locking member 180 towardsthe suture anchoring members 22, 22′. Further drawing the loops 30, 32,30′, 32′ can draw the first tissue 12 in close proximity with the secondtissue 14 in a desired relationship and subsequently compress the firsttissue 12, thereby creating tension in the suture constructs 20, 20′.FIG. 17 illustrates the suture constructs 20, 20′ in a tensioned state.With tension in the suture constructs 20, 20′, one or more of thetensioning strands 42, 44, 42′, 44′ can be cut to remove excess lengthwhere the ends of the one or more strands are not to be attached to thehumerus 72. Alternately, the tensioning strands 42, 44, 42′, 44′ can bedrawn past an end of the rotator cuff 70 and attached to the humerus 72as shown. While drawing and/or attaching one or more of the tensioningstrands 42, 44, 42′, 44′, the ends 504, 506 can be drawn past the end ofthe rotator cuff 70 and attached to the humerus 72.

With particular reference to FIG. 18, another TFD 600 and surgicalmethod of using the TFD 600 for affixing two tissues according to thepresent teachings will now be described. The TFD 600 can be used, forexample, to affix the rotator cuff 70 to the humerus 72. The TFD 600 andthe method illustrate alternate features according to the presentteachings including overlapping tensioning members of suture constructsin a criss-cross fashion and securing the tensioning members of eachsuture construct to the humerus 72 at at least two separate locations.An overlapping structure of the tensioning members can engage andthereby further affix the rotator cuff 70 to the humerus 72. Theoverlapping structure can further reduce localized stress in one or boththe rotator cuff 70 and the humerus 72 by distributing the loadstransmitted between the TFD 600 and the rotator cuff 70 and humerus overa larger area and creating a larger area of compression.

According to the example shown in FIG. 18, the TFD 600 can include afirst suture construct 602, a second suture construct 604, and a lockingmember 606. The first and second suture constructs 602, 604 each caninclude at least two adjustable loops tensioned by correspondingtensioning members. For example, the first suture construct 602 caninclude four adjustable loops 610 tensioned by four correspondingtensioning strands 612 as shown. Similarly, the second suture construct604 can include four adjustable loops 614 tensioned by fourcorresponding tensioning strands 616. The adjustable loops 610, 614 canbe created using various suturing techniques and devices. According tothe example shown in FIG. 18, the adjustable loops 610, 614 can becreated by passing a suture through the rotator cuff 70 using a whipand/or a mattress stitching technique. In various implementations, theadjustable loops 610, 614 can be created from separate sutures attachedto the humerus 72 in a manner similar to that discussed below withreference to FIG. 21. The adjustable loops 610, 614 can create a seriesof loops spaced apart in a substantially linear arrangement along a lineor axis 618 as shown. The linear arrangement or axis 618 can extend in adirection substantially transverse to a direction in which the rotatorcuff 70 tensions due to muscle contraction.

The tensioning strands 612, 616 can exit the same proximal side of therotator cuff 70 that the adjustable loops 610, 614 are disposed, and ina substantially linear arrangement in the direction in which the rotatorcuff 70 tensions due to muscle contraction. The tensioning strands 612,614 can exit on either side of the adjustable loops 610, 614. Forexample, the tensioning strands 610, 614 can each exit in closeproximity to the corresponding adjustable loops 610, 614 on a sideclosest to an end of the rotator cuff 70 as shown. The tensioningstrands 612, 616 can be attached to the humerus 72 in at least twoselected areas separated in the same direction in which the adjustableloops 610, 614 are arranged.

According to the example shown in FIG. 18, the tensioning strands 612,616 can be secured at two locations indicated by reference numerals 620,622. More specifically, at least one of each of the tensioning strands612 and the tensioning strands 616 can be attached at the first location620 and at least another one of each of the tensioning strands 612 andthe tensioning strands 616 can be attached at the second location 622.For exemplary purposes, the tensioning strands 612, 614 can be attachedto the first and second locations 620, 622 in an alternating arrangementas shown. When secured, the tensioning strands 612, 616 secured at thefirst location 620 can overlap the tensioning strands 612, 616 securedat the second location 622 in a criss-cross fashion. The locking member606 can extend through each of the loops 610, 614 and can include afirst end 630 and a second end 632 that are attached at the firstlocation 620 and the second location 622, respectively.

With continued reference to FIG. 18, an exemplary method of using theTFD 600 will now be described. The method can include creating the loops610, 614 and tensioning strands 612 and 616 to pass through and exit therotator cuff 70 and attaching the loops 610, 614 to the humerus 72. Theadjustable loops 610 can be attached to the humerus 72 using a firstsuture anchoring member such as, for example, the suture anchoringmember 22 discussed above. Similarly, the adjustable loops 614 can beattached to the humerus 72 using a separate, second suture anchoringmember in a similar manner.

Next, with the adjustable loops 610, 614 in an untensioned state, thelocking member 606 can be passed through and positioned within the loops610, 614 such that the ends 630, 632 extend past end loops of theadjustable loops 610, 614. Once the locking member 606 is routed throughthe loops 610, 614, the tensioning strands 612, 616 can be selectivelypulled to cinch the loops 610, 614 around the locking member 606 and todraw the locking member 606 into engagement with the rotator cuff 70.Next, the tensioning strands 612, 616 can be further selectively pulledto draw the locking member 606 towards the humerus 72. Further drawingthe loops 30, 32, 30′, 32′ can draw the rotator cuff 70 in closeproximity with the humerus 72 in a desired relationship and subsequentlycompress the rotator cuff 70 against the humerus 72, thereby creatingtension in the loops 610, 614. FIG. 18 illustrates the loops 610, 614 ina tensioned state.

While maintaining the tension in the loops 610, 614, a first pair of thetensioning strands 612 and a first pair of the tensioning strands 616can be drawn together and attached at the selected location 620.Subsequently, a second pair of the tensioning strands 612 and a secondpair of the tensioning strands 616 can be drawn together and attached atthe selected location 622. When attached in the foregoing manner, thefirst and second pairs of the tensioning strands 612, 616 can extend atangles with respect to the axis 618 and overlap in a criss-cross fashionto create an overlapping structure that compresses an end portion of therotator cuff 70 against the humerus 72. In this way, the overlappingstructure can further secure the rotator cuff 70 to the humerus 72.

With particular reference to FIG. 19, another TFD 700 and surgicalmethod of using the TFD 700 for affixing two tissues according to thepresent teachings will now be described. The TFD 700 can be used, forexample, to affix the rotator cuff 70 to the humerus 72. The TFD 700 andthe method illustrate alternate features according to the presentteachings including using one or more portions of a suture construct tocreate a locking member for adjustable loops of the suture construct andsecuring the portions at a remote location.

According to the example shown in FIG. 19, the TFD 700 can include afirst suture construct 702 and a second suture construct 704. The firstand second suture constructs 702, 704 can be substantially similar tothe suture constructs 20, 20′ and can be attached to the humerus 72 insubstantially the same way as the suture constructs 20, 20′. The firstsuture construct 702 can include a first adjustable loop 710 tensionedby a tensioning strand 712 and a second adjustable loop 714 tensioned bya tensioning strand 716. The first adjustable loop 710 and thetensioning strand 712 can pass through a common first aperture 720formed through the rotator cuff 70 and exit on the same side. Thetensioning strand 712 can pass through the second adjustable loop 714.The second adjustable loop 714 and tensioning strand 716 can passthrough a common second aperture 722. The tensioning strand 716 can passthrough the adjustable loop 710.

The second suture construct 704 can include a third adjustable loop 730tensioned by a tensioning strand 732 and a fourth adjustable loop 734tensioned by a tensioning strand 736. The third adjustable loop 730 canpass through a first aperture 740 and the tensioning strand 732 can passthrough a separate, second aperture 742 and through the adjustable loop730. The fourth adjustable loop 734 can pass through a third aperture744 and the tensioning strand 736 can pass through a separate, fourthaperture 746 and through the fourth adjustable loop 734. The adjustableloops 710, 714, 730, 734 can be spaced apart along a line or axis 750and the apertures 720, 722, 740, 744 can extend at angles with respectto the axis 750. For example, the apertures 720, 722 can extend atangles of, for example, approximately forty-five degrees (45°) so thatthe adjustable loops 710, 714 can face each other and to facilitate thepassage of the tensioning strands 712, 716. The apertures 740, 744 canextend at angles so that the adjustable loops 730, 734 face towards theapertures 742, 746 and thereby facilitate the passage of the tensioningstrands 732, 736. The tensioning strands 712, 716, 732, 736 can be cutto remove excess length and/or attached to a selected area of thehumerus 72 at a single, remote location 752 as shown or, alternately,can be secured at two or more remote locations.

With continued reference to FIG. 19, an exemplary method of using theTFD 700 can include attaching the first and second suture constructs702, 704 to the humerus 72 and passing the adjustable loops 710, 714,730 through the respective apertures 720, 722 of rotator cuff 70. Themethod can further include passing the tensioning strands 712, 716, 732through the respective apertures 720, 722, 734. In variousimplementations, the tensioning strands 712, 716 can be passed throughthe apertures 720, 722 at the same time as the respective adjustableloops 710, 714 are passed.

Next, with the first suture construct 702 in an untensioned state, anend of the tensioning strand 712 can be inserted through the secondadjustable loop 714 and an end of the tensioning strand 716 can beinserted through the adjustable loop 710. Next, the tensioning strands712, 714 can be selectively pulled to cinch the adjustable loops 710,714 around the tensioning strands 712, 714 and engage intermediateportions of the tensioning strands 712, 714 with the rotator cuff 70.Once the tensioning strands 712, 714 are engaged, the tensioning strands712, 714 can be further selectively pulled to draw the rotator cuff 70in close proximity to the humerus 72. Once the rotator cuff 70 ispositioned against the humerus 72 in a desired relationship, thetensioning strands 712, 714 can be attached to the humerus 72 in tensionto retain the relationship.

With the second suture construct 704 in an untensioned state, an end ofthe tensioning strand 732 can be inserted through the adjustable loop730 and pulled to cinch the adjustable loop 730 and engage anintermediate portion of the tensioning strand 732 with the rotator cuff70. Once engaged in the foregoing manner, the tensioning strand 732 canbe further pulled to draw the rotator cuff 70 into a desiredrelationship and subsequently attached in tension to the humerus 72.

With particular reference to FIG. 20, another TFD 800 and surgicalmethod of using the TFD 800 for affixing two tissues according to thepresent teachings will now be described. The TFD 800 can be used, forexample, to affix the rotator cuff 70 to the humerus 72. The TFD 800 caninclude a suture construct 802 having at least two adjustable loops andat least one locking member that engages the adjustable loops. Accordingto the example shown in FIG. 20, the suture construct 802 can includefour adjustable loops 804, 806, 808, 810 and three locking members 820,822, 824. In various implementations, the adjustable loops 804, 806 andthe adjustable loops 808, 810 can be created using the suture construct20 and the suture construct 20′, respectively.

The locking member 820, locking member 822, and locking member 824 canhave ends 830, 832, ends 834, 836, and ends 838, 840, respectively. Thelocking member 820 can extend through and engage the loops 804, 806. Thelocking member 822 can extend through and engage the loops 806, 808. Thelocking member 824 can extend through and engage the loops 808, 810. Theends 830, 832, 834 can be attached to a selected area of the humerus 72at a first location indicated by reference numeral 850, and the ends836, 838, 840 can be attached at a second location indicated byreference numeral 852.

With continued reference to FIG. 20, an exemplary method of using theTFD 800 can include attaching the loops 804, 806, 808, 810 to thehumerus 72 and passing the loops 804, 806, 808, 810 through the rotatorcuff 70. The loops 804, 806, 808, 810 can be passed so as to extendalong a line or axis 854 and face in a second direction substantiallyperpendicular to the axis 854. With the loops 804, 806, 808, 810 in anuntensioned state, the ends 830, 832, the ends 834, 836, and the ends838, 840 can be passed through the loops 804, 806, the loops 806, 808,and the loops 808, 810, respectively, in the second direction. Whenpassed in the foregoing manner, portions of the locking members 804,806, 808, 810 can span the corresponding loops 804, 806, 808, 810. Next,the ends 830, 832, 834, 836, 838, 840 can be pulled to create tension inthe loops 804, 806, 808, 810 and to draw the rotator cuff 70 into closeproximity with the humerus 72 in a desired relationship. With therotator cuff 70 and the humerus 72 in the desired relationship, the ends830, 832, 834, 836, 838, 840 can be attached to the humerus 72 at therespective locations 850, 852 in a tensioned state.

With particular reference to FIG. 21, another exemplary TFD 900 andsurgical method of using the TFD 900 for affixing the first and secondtissues 12, 14 according to the present teachings will now be described.The TFD 900 can be used, for example, to affix the rotator cuff 70 tothe humerus 72. The TFD 900 and the method illustrate alternate featuresaccording to the present teachings. The alternate features can includeengaging a locking member with at least two adjustable loops disposed onone side of a first tissue and drawing the locking member and the firsttissue into engagement with a second tissue using tensioning strandsdisposed between the first and second tissues.

According to the example shown in FIG. 21, the TFD 900 can include aflexible suture construct 902 created by suture strands 904, 906. Thesuture strand 904 can be passed through the first tissue 12 to createloops 910, 912 that extend from a first side of the first tissue 12opposite a second side to be engaged with the second tissue 14. Thesuture strand 904 can be further passed through the first tissue 12 suchthat ends 914 and 916 exit and extend from the first tissue 12 on thesecond side of the tissue facing the second tissue 14. The suture strand906 can be passed through the first tissue 12 to create loops 920, 922that extend from the first side of the first tissue 12 and ends 924, 926that exit and extend from the second side of the first tissue 12. Eachof the loops 910, 912, 920, 922 can be created by passing the respectivesuture strands 904, 906 through a single aperture or, alternately,through separate apertures in the first tissue 12. Ends of the suturestrands 904, 906 can be secured to the second tissue 14 in any desiredmanner such as, for example, using one or more suture anchors. While twosuture strands 904, 906 forming four loops 910, 912, 920, 922 are shown,fewer or more suture strands can be used where fewer or more loops aredesired.

With continued reference to FIG. 21, an exemplary method of using theTFD 900 can include positioning a locking member (not shown) within theloops 910, 912, 920, 922 and subsequently engaging the loops 910, 912,920, 922 with the first tissue 12 via the locking member. The loops 910,912, 920, 922 can be engaged by pulling on the ends 914, 916, 924, 926to cinch the loops 910, 912, 920, 922 into engagement with the lockingmember and to draw the locking member into engagement with the firsttissue 12. The locking member can include one or more features of thelocking members 24, 100, 120, 140, 160, 180, 200, 220, 240. With theloops 910, 912, 920, 922 engaged, the ends 914, 916, 924, 926 can beselectively pulled to draw the first tissue 12 into close proximity withthe second tissue 14 in a desired relationship. The desired relationshipcan be maintained by maintaining tension in the loops 910, 912, 920,922. With the first and second tissues 12, 14 in the desiredrelationship, the ends 914, 916, 924 and 926 can be drawn and attachedto the second tissue 14 in tension to retain the relationship.

With reference to FIGS. 22-24, another TFD 1000 and surgical method ofusing the TFD 1000 for affixing the rotator cuff 70 to the humerus 72according to the present teachings will now be described. The TFD 1000can include two or more flexible anchors 1002, 1004, one or moreself-locking, flexible suture constructs 1006, and a locking member1010. For example, the TFD 1000 can include four (4) flexible anchors1002, four (4) flexible anchors 1004, four (4) flexible sutureconstructs 1006, and one (1) locking member 1010 as shown. The lockingmember 1010 can incorporate one or more features of the locking members24, 100, 120, 140, 160, 180, 200, 220, 240 discussed above.

With particular reference to FIG. 22, the flexible anchors 1002, 1004can be elongate members having a sleeve or tubular construction. Theflexible anchors 1002, 1004 can be configured to attach to the humerus72 within respective bores 1012 formed in the humerus 72. For example,the flexible anchors 1002, 1004 can deform between a first shapeconfigured to be received within the bores 1012 and a second shapelarger than the first shape configured to engage the bores 1012. Theflexible anchors 1002, 1004 can include longitudinal passages 1020, 1022and openings 1024, 1026, 1028, 1030 extending through respective walls.The flexible suture construct 1006 can include a braided body 1040 andtensioning strands 1042, 1044 that form a self-locking adjustable loopincluding loop sections 1050, 1052. The braided body 1040 can define alongitudinal passage 1054 and openings 1056, 1058 in communication withthe longitudinal passage 1054. The tensioning strands 1042, 1044 canextend from opposite ends of the braided body 1040.

The loop sections 1050, 1052 can be formed and coupled to the flexibleanchors 1002, 1004 by passing the braided body 1040 and the tensioningstrand 1042 through the flexible anchors 1002, 1004 as shown. Morespecifically, the tensioning strand 1042 and the braided body 1040 canpass through the openings 1024, 1026 and the longitudinal passage 1020of the flexible anchor 1002. The tensioning strand 1042 can further passthrough the openings 1028, 1030 and longitudinal passage 1022 of theflexible anchor 1004 and the openings 1056, 1058 and the longitudinalpassage 1054 of the braided body 1040. When coupled, the flexible anchor1002 and the braided body 1040 can be disposed at a first end 1060 andthe flexible anchor 1004 can be disposed at a second end 1062. Furtherdetails of the flexible anchors 1002, 1004 and the flexible sutureconstruct 1006 are disclosed in commonly assigned U.S. patentapplication Ser. No. 12/915,962, the entire disclosure of which isexpressly incorporated herein by reference.

With continued reference to FIGS. 22-24, the method of using the TFD1000 can include selectively adjusting a size of the loop sections 1050,1052 by pulling on the tensioning strand 1042. The size of the loopsections 1050, 1052 can be adjusted to provide a desired length betweenthe first and second ends 1060, 1062. The first ends 1060 can be passedthrough apertures 1068 in the rotator cuff 70 along a line or axis 1070and the flexible suture anchors 1002 can secured within the respectivebores 1012 formed in the humerus 72 at proximal locations 1072. Theproximal locations 1072 can be located beneath the rotator cuff 70 whenthe rotator cuff 70 is secured in a desired position. The locking member1010 can be positioned on an outer surface 1074 of the rotator cuff 70to extend between the flexible suture constructs 1006, and generallyparallel to the axis 1070. The second ends 1062 can be drawn over thelocking member 1010, past an end 1080 of the rotator cuff 70, andsecured within the respective bores 1012 formed in the humerus 72 atdistal locations 1076 adjacent the end 1080. The distal locations 1076can be spaced apart from the proximal locations 1072 and can be disposedadjacent the end 1080 of the rotator cuff 70 as best seen in FIG. 24.When secured, tension in the flexible suture constructs 1006 cancompress the locking member 1010. The tensioning strands 1042, 1044 canbe cut to a desired length, for example, flush to the outer surface 1074of the rotator cuff 70.

The foregoing description of the embodiments has been provided forpurposes of illustration and description. It is not intended to beexhaustive or to limit the disclosure. Individual elements or featuresof a particular embodiment are generally not limited to that particularembodiment, but, where applicable, are interchangeable and can be usedin a selected embodiment, even if not specifically shown or described.The same may also be varied in many ways. Such variations are not to beregarded as a departure from the disclosure, and all such modificationsare intended to be included within the scope of the disclosure.

What is claimed is:
 1. A method of attaching soft tissue to bone,comprising: locating, over a first aperture and over a second aperture,respectively, in an outer surface of a soft tissue that is positionedover a bone; at least part of a first adjustable loop and at least partof a second adjustable loop which are anchored to the bone via suturematerial that passes through the first aperture and through the secondaperture, respectively, to the bone; positioning a locking member alongthe outer surface of the soft tissue such that the locking memberextends through the first adjustable loop and through the secondadjustable loop; and reducing a size of the first adjustable loop and asize of the second adjustable loop as the locking member is extendingthrough the first adjustable loop and through the second adjustable loopso as to compress the soft tissue segment between the locking member andthe bone.
 2. The method of claim 1, wherein the first adjustable loopand the second adjustable loop are formed from a single piece of braidedsuture.
 3. The method of claim 2, wherein the single piece of braidedsuture includes a first free end and a second free end, the first freeend passing through a first longitudinal passage in the braided sutureto form the first adjustable loop and the second free end passingthrough a second longitudinal passage in the braided suture to form thesecond adjustable loop, the first free end pullable to reduce the sizeof the first adjustable loop, the second free end pullable to reduce thesize of the second adjustable loop.
 4. The method of claim 1, whereinthe first adjustable loop is coupled to a first anchor that is receivedin the bone at a first location and the second adjustable loop iscoupled to a second anchor that is received in the bone at a secondlocation.
 5. The method of claim 1, wherein the locking member comprisesa suture.
 6. The method of claim 1 further comprising adjusting a lengthof the locking member as the locking member is extending through thefirst adjustable loop and through the second adjustable loop.
 7. Themethod of claim 6, wherein the locking member comprises a suture, andwherein adjusting the length of the locking member includes pulling on afree end of the suture.
 8. The method of claim 1, wherein the softtissue is a rotator cuff and the bone is a humerus.
 9. A method ofattaching soft tissue to bone; comprising: locating a first anchor in abone with a first adjustable suture construct that is coupled to thefirst anchor extending from the first anchor and through a soft tissuethat is positioned over the bone so that at least part of a firstadjustable loop of the first adjustable suture construct is positionedalong an outer surface of the soft tissue; locating a second anchor inthe bone with a second adjustable suture construct that is coupled tothe second anchor extending from the second anchor and through the softtissue so that at least part of a second adjustable loop of the secondadjustable suture construct is positioned along the outer surface of thesoft tissue; positioning a locking member along the outer surface of thesoft tissue such that the locking member extends through the firstadjustable loop and through the second adjustable loop; and reducing asize of the first adjustable loop and a size of the second adjustableloop as the locking member is extending through the first adjustableloop and through the second adjustable loop so as to compress the softtissue between the locking member and the bone.
 10. The method of claim9, wherein the locking member is flexible.
 11. The method of claim 9,wherein the locking member comprises a suture material.
 12. The methodof claim 9 further comprising adjusting a length of the locking memberas the locking member is extending through the first adjustable loop andthrough the second adjustable loop.
 13. The method of claim 12, whereinthe locking member comprises a suture material, and wherein adjustingthe length of the locking member includes pulling on a free end of thesuture material.
 14. The method of claim 9, wherein at least one of thefirst anchor and the second anchor comprises a flexible tube.
 15. Themethod of claim 9, wherein the soft tissue is a rotator cuff and thebone is a humerus.